Contemporary Approaches to Relapse Prevention in Substance Abuse Treatment

1. Relapse Prevention G. Alan Marlatt, Ph.D. University of Washington Addictive Behaviors Research Center abrc@u.washington.edu http://depts.washington.edu/abrc

2. Contemporary Approaches to Substance Abuse Treatment • 12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAA • Traditional Minnesota Model Inpatient Treatment - Detox, medical supervision, disease model, AA, group, drug education • Intensive Outpatient Minnesota Model Treatment - Medical supervision, individual sessions, disease model, AA, groups • Therapeutic Communities for Substance Abuse - 24-hour residential setting, norms, responsibility, encounter groups • Pharmacological Therapy – Antabuse, methadone, LAMM, buprenorphine, naltrexone, etc • Psychological Therapies – Group, couple, and individual therapy • Behavior Therapy – Aversion therapy, cue exposure, skills training, contingency management, community reinforcerment • Cognitive-Behavioral Therapy – Relapse Prevention, coping skills training, cognitive therapy, lifestyle modification

10. Brickman’s Model of Helping & Coping Applied to Addictive Behaviors Is the person responsible for changing the addictive behavior? YES NO Is the person responsible for the development of the addictive behavior? YES NO MORAL MODEL (War on Drugs) Relapse = Crime or Lack of Willpower SPIRITUAL MODEL (AA & 12-Steps) Relapse = Sin or Loss of Contact with Higher Power COMPENSATORY MODEL (Cognitive-Behavioral) Relapse = Mistake, Error, or Temporary Setback DISEASE MODEL (Heredity & Physiology) Relapse = Reactivation of the Progressive Disease

14. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors BIOLOGICAL FACTORS • Biological vulnerability and genetic predisposition in interaction with certain facilitating environments create problems and eventually disease. • Pharmacological impact of excessive use of alcohol and other drugs on body chemistry, physiology , and the organ systems of the body. • Tolerance – Increased frequency of use and higher doses over time. • Withdrawal – Negative effects of cessation of addictive behaviors. • Higher risk of developing specific physical disorders (diseases) associated with the chronic and excessive use of particular substances.

15. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors PSYCHOLOGICAL FACTORS • Motivation – Stages of habit initiation and stages of habit change. • Expectancies – Positive outcomes of drug use and self-efficacy. • Attributions – Effects of substance use and reasons for relapse. • Sensation-Seeking – Excessive need for stimulation • Impulsivity – Inability to effectively control or restrain behavior. • Negative Affect – Dysphoric moods such as anxiety & depression. • Poor Coping – Deficits in cognitive and behavioral skills or inhibitions in the ability to perform behaviors due to the effects of anxiety.

16. Biopsychosocial Factors in Development and Maintenance of Addictive Behaviors SOCIOCULTURAL FACTORS • Family History – Dysfunctional family settings especially parental alcohol and drug problems and parental abuse or neglect of children. • Peer Influences – Social pressure to engage in risk-taking behaviors including substance use especially when related to gang membership. • Culture and Ethnic Background – Norms and religious beliefs that govern the use of alcohol and drugs and ethnic variations the body’s rate and efficiency of metabolizing drugs and alcohol. • Media/Advertising – Societal emphasis on immediate gratification and glorification of the effects of alcohol and drug use.

25. Analysis of High-Risk Situations for RelapseAlcoholics, Smokers, and Heroin Addicts

27. “Let’s just go in and see what happens.”

30. Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and Overeaters

31. A Cognitive Behavioral Model of the Relapse Process

32. Relapse Prevention: Specific Intervention Strategies

33. Skill-Training with Alcoholics: One- Year Follow-Up Results Days of Continuous Drinking SD = 62.2 p < .05 SD = 6.9 (Mean = 44.0) (Mean = 5.1)

34. Skill-Training with Alcoholics: One- Year Follow-Up Results Number of Drinks Consumed SD = 2218.4 p < .05 SD = 507.8 (Mean = 399.8) (Mean = 1592.8)

35. Skill-Training with Alcoholics: One- Year Follow-Up Results Days Drunk SD = 17.8 p < .05 SD = 17.8 (Mean = 64.0) (Mean = 11.1)

36. Skill-Training with Alcoholics: One- Year Follow-Up Results Controlled Drinking SD = 17.8 P = N.S. SD = 2.6 (Mean = 4.9) (Mean = 1.2)

39. Empirical Support:Review of 24 RCTsKathleen M. Carroll (1996) Relapse Prevention: • Does not usually prevent a lapse better than other active treatments, but is more effective at “Relapse Management,” i.e. delaying first lapse and reducing duration and intensity of lapses • Particularly effective at maintaining treatment effects over long term follow-up measurements of 1-2 years or more • “Delayed emergence effects” in which greater improvement in coping occurs over time • May be most effective for “more impaired substance abusers including those with more severe levels of substance abuse, greater levels of negative affect, and greater perceived deficits in coping skills.” (Carroll, 1996, p.52)

40. Empirical Support: Meta-Analytic ReviewIrvin, Bowers, Dunn & Wang (1999) • Reviewed 17 controlled studies to evaluate overall effectiveness of the RP model as a substance abuse treatment • Statistically identified moderator variables that may reliably impact the outcome of RP treatment • “Results indicate that RP is highly effective for both alcohol-use and substance-use disorders”

41. Empirical Support: Meta-Analytic ReviewIrvin, Bowers, Dunn & Wang (1999) Moderator Variables with Significant Impact on RP Effectiveness: • Group format more effective than individual therapy format • More effective as “stand alone” than as aftercare • Inpatient settings yielded better outcomes than outpatient • Stronger treatment effects on self-reported use than on physiological measures • While effective across all categories of substance use disorders, stronger treatment effects found for substance abuse than alcohol abuse

42. Relapse Prevention Recognition

44. The “Black and White” Model of Relapse

48. The Abstinence Violation Effect • Emotional-guilt, blame, failure, etc. • Cognitive-Internal, stable,global, uncontrollable • Self-awareness increase • Comparison to Internalized Standards-greater difference, more guilt • Behavioral Reaction-dominant habitual response • Cognitive Reaction-resolve discrepancy